The patient came to the clinic 28-July-2015 complaining of neck pain with both shoulder pain for 3 months with gradual onset associated with feeling of four limbs weakness with inability to stand and walk independently with tendency to fall down. She is in wheelchair for 2 months. The patient is a known diabetic and hypertensive for 15 years in treatment.

On examination: the patient is in wheelchair. He profound weak both hands 3/5 extension and flexion both hands with weak deltoids, triceps and biceps both upper limbs 3-4/5, more weak in the left. There is Hoffmann both sides with exaggerated deep reflexes with no sensory apparent disturbances. Both lower limbs muscles proximal and distal are weak 3-4/5, more weal the distal muscles with Babinski positive both side with persistent clonus and SLRS 40 due to weakness. The micturition and sphecteric functions are normal.

The patient was sent for investigations. MRI of the brain performed 09-August-2015 showed periventricular changes compatible with age. There are no major problems in the brainstem to explain her condition. MRI cervical performed 15-Auagust-2015 showed severe cervical stenosis of C3-4 and C5-6 with malacia of the spinal cord more behind C3-4. Cardiac consultation performed and anticoagulation stopped.

Decompressive laminectomy C3-4-5 and C6 was performed. The ligamentum flavum was severely constricting the spinal cord at C3-4 level and was adherent to the dura. Sharp dissection of the dura to remove the constricting bands. The dura was relatively thick at this area with fibrotic tissues holding the suspicion of previous trauma. Strict hemostasis and routine closure.

Smooth postoperative recovery. The power of the four limbs improved slightly after surgery. The patient was sent to the ward.

The patient has severe stenosis with malacia of the spinal cord. The course is progressive and the sooner the decompression, the better the outcome.

Consider if the patient having other pathologies such as ALS. First MRI of the brain did not show the signs of this or other pathologies and nor the clinical examination. Even if there is coincidental pathologies, decompression is a must.